Combined simultaneous endoscopic endonasal and transcranial surgery using high-definition three-dimensional exoscope for malignant tumors of the anterior skull base

BACKGROUND

Advanced surgical interventions are required to treat malignancies in the anterior skull base (ASB). This study investigates the utility of endoscopic endonasal and transcranial surgery (EETS) using a high-definition three-dimensional exoscope as an alternative to traditional microscopy.

METHODS

Six patients with carcinomas of varying histopathologies underwent surgery employing the EETS maneuver, which synchronized three distinct surgical modalities: harvesting of the anterolateral thigh flap, initiation of the transnasal technique, and initiation of the transcranial procedure.

RESULTS

The innovative strategy enabled successful tumor resection and skull base reconstruction without postoperative local neoplastic recurrence, cerebrospinal fluid leakage, or neurological deficits.

CONCLUSION

The integration of the exoscope and EETS is a novel therapeutic approach for ASB malignancies. This strategy demonstrates the potential of the exoscope in augmenting surgical visualization, enhancing ergonomics, and achieving seamless alignment of multiple surgical interventions. This technique represents a progressive shift in the management of these complex oncological challenges.

Introducing next-generation transcranial surgery with the head-mounted 3D View Vision display in extracorporeal microsurgery: illustrative cases

BACKGROUND

Exoscopy in neurosurgery offers various advantages, including increased freedom of the viewing axis while the surgeon maintains a comfortable upright position. However, the optimal monitor positioning to avoid interference with surgical manipulation remains unresolved. Herein, the authors describe two cases in which a three-dimensional head-mounted display (3D-HMD) was introduced into a transcranial neurosurgical procedure using an exoscope.

OBSERVATIONS

Case 1 was a 50-year-old man who presented with recurrent epistaxis and was diagnosed with an olfactory neuroblastoma that extended from the nasal cavity to the anterior cranial base and infiltrated the right anterior cranial fossa. Case 2 was a 65-year-old man who presented with epistaxis and was diagnosed with a left-sided olfactory neuroblastoma. In both cases, en bloc tumor resection was successfully performed via a simultaneous exoscopic transcranial approach using a 3D-HMD and an endoscopic endonasal approach, eliminating the need to watch a large monitor beside the patient.

LESSONS

This is the first report of using a 3D-HMD in transcranial surgery. The 3D-HMD effectively addressed issues with the field of vision and concentration while preserving the effectiveness of traditional microscopic and exoscopic procedures when observed on a 3D monitor. Combining the 3D-HMD with an exoscope holds the potential to become a next-generation surgical approach.

3D Exoscopes in Experimental Microanastomosis: A Comparison of Different Systems

Background: In recent years, three-dimensional exoscopes have been increasingly applied in neurosurgery. Multiple exoscopic systems are available, all offering specific features. In this study, we assessed practical and visualization performance of four different exoscopic systems in a highly challenging microsurgical procedure, and evaluated whether these affected the quality of work. Methods: We included four different exoscopes: Olympus ORBEYE, Zeiss KINEVO, Storz VITOM, and Aesculap AEOS. With each exoscope, ten experimental bypass procedures were carried out on chicken wing vessels at a depth of 3 cm. We evaluated the quality of the anastomoses, the practical considerations for the setup of the exoscopic systems, and the visualization quality by tracking the number of unnecessary movements. Results: All included exoscopes enabled us to perform the bypass procedures with mostly adequate or excellent results. Surgically, the most pronounced difference between the exoscopes was the duration of the procedure, which was mainly due to the number of unnecessary movements. Practically, the exoscopes differ highly which is important when considering which exoscope to apply. Conclusions: This is the first study comparing different exoscope systems while performing the same challenging microsurgical procedure. We found major practical differences between the exoscopes that determine the suitability of an exoscope based on the demands and conditions of the surgical procedure. Therefore, preprocedural practical training with the exoscope is required.

The Characteristic of Light Sources and Fluorescence in the 3-Dimensional Digital Exoscope "ORBEYE" for 5-Aminolevulinic Acid-Induced Fluorescence-Guided Surgery Compared with a Conventional Microscope

BACKGROUND

The ORBEYE (ORB), an innovative 3-dimensional digital exoscope, is an equipped system for fluorescence-guided surgery with 5-aminolevulinic acid. Therefore, this study aimed to verify the characteristics of fluorescence-guided surgery with 5-aminolevulinic acid and excitation light source with ORB.

METHODS

The same operative field of glioblastoma was recorded under blue light (BL) excitation using a conventional microscope (MS) and ORB. For in vitro studies, the energy of 405-nm wavelength light in white light and BL modes of each scope was examined in various focal lengths. To examine the degree of photobleaching with BL for each scope, protoporphyrin IX-soaked filter papers were continuously exposed with BL of an MS and ORB, and the video-recorded red fluorescence intensity was analyzed.

RESULTS

The color tone of tumor-induced red fluorescence was remarkably different under each scope. Furthermore, nonfluorescent normal structures without red fluorescence were well recognized under ORB. The energy of 405-nm wavelength light in BL was significantly higher in ORB than that in an MS, especially in the short focal length. With continuous BL excitation to filter papers, the relative red fluorescence intensity of filter papers was significantly decreased over time in ORB than in an MS. In low protoporphyrin IX concentration, the difference was more significant.

CONCLUSIONS

With ORB, the good visibility due to BL energy as compared with an MS might improve the surgical manipulation even in BL mode. However, the weak fluorescent tissue and short focal length should be carefully considered because photobleaching might be critical for FGS.

Exoscopic carotid endarterectomy using movable 4K 3D monitor: Technical note

Background:

Carotid endarterectomy (CEA) using conventional surgical microscope has been already established as golden standard. Recently, exoscope was introduced into the field of neurosurgery, and various merits of it have been reported. We report the experiences of exoscopic CEA using a movable 4K 3D monitor and discuss the feasibility of it.

Methods:

We report a consecutive series of 15 cases of exoscopic CEA for internal carotid artery (ICA) stenosis using a movable 4K 3D monitor between January 2020 and April 2021. We utilized ORBEYE as an exoscope system and a 31-inch movable 4K 3D monitor, which was installed in the Maquet Moduevo ceiling supply unit.

Results:

In all 15 cases, the procedures were accomplished only using the ORBEYE. There were no operative complications due to the use of the exoscope. In response to the operative site, the 4K 3D monitor was moved to face the operator. Even when the angle of the visual axis of the exoscope against the horizontal plane was small during the surgical manipulation in the distal portion of ICA, the operator was able to maintain a comfortable posture.

Conclusion:

Using the movable 4K 3D monitor, exoscopic CEA can be performed ergonomically. The operator can manipulate the distal portion of the ICA or proximal portion of the common carotid artery in a comfortable posture and face the monitor by adjusting its position.

Four Hands Surgery for Intracerebral Hemorrhage using Orbeye: Educational Values and Ergonomic Advantages - A Technical Note

We have developed a new educational approach to microsurgery in which a trainee and supervisor can cooperate with “4 hands” using the exoscope. We evaluated 4-hands surgery for intracranial hemorrhage (ICH) using the exoscope to validate the educational value and ergonomic advantages of this method. Thirty consecutive patients who underwent surgery for ICH using the exoscope between December 2018 and May 2020 were studied retrospectively. All operations were performed by a team comprising a supervisor (assistant) and a trainee (main operator). The assistant set the visual axis of the exoscope, and adjusted focus and magnification as a scopist. After setting the ORBEYE, the supervisor helped retract the brain and withdraw and irrigate the hematoma using suction tubes or brain retractors. Moreover, the trainee evacuated the hematoma with a suction tube and coagulated using bipolar forceps. Patient background and results of treatment were evaluated. Intraoperative postures of the operators were observed, and schemas compared with the use of a conventional microscope were developed. All microsurgical procedures were accomplished by a trainee with a supervisor using only the exoscope. During the surgery, the surgeons could work in a comfortable posture, and the supervisor and trainee could cooperate in microsurgical procedures using their four hands. The results of the present case series concerning evacuation of ICH were not inferior to those described in previous reports. To increase opportunities for education in microsurgery, 4-hands surgery for ICH using the exoscope appears feasible and safe and offered excellent educational value and ergonomic advantages.

Beyond magnification and illumination: preliminary clinical experience with the 4K 3D ORBEYE™ exoscope and a literature review

BACKGROUND

The operating microscope (OM) is an invaluable tool in neurosurgery but is not without its flaws. The ORBEYE™ (Olympus, Tokyo, Japan) is a 4K 3D exoscope aspiring to offer similar visual fidelity but with superior ergonomics. 2D visualisation was a major limitation of previous models which newer 3D exoscopes attempt to overcome. Here, we present our initial experience using a 4K 3D exoscope for neurosurgical procedures.

OBJECTIVE

To evaluate the feasibility of the ORBEYE™ exoscope in performing neurosurgery and review of the literature.

METHODS

All patients undergoing neurosurgery performed by a single surgeon, using the ORBEYE™, were assessed. Descriptive statistics and data relating to complications and operative time were recorded and analysed. An anecdotal literature review was performed for the experience of other authors using 4K 3D exoscopes in neurosurgery and compared to our subjective experience with the ORBEYE™.

RESULTS

18 patients underwent surgery using the ORBEYE™. There were no 30-day post-operative complications observed. Our experience and that of other authors suggests that the ORBEYE™ offers comparable visualisation to the traditional OM, with superior ergonomics and an enhanced experience for assistants and observers.

CONCLUSION

Neurosurgery can be performed safely and effectively with the ORBEYE™, with improved ergonomics and educational benefit. There appears to be a short learning curve provided one has experience with endoscopic surgery and the use of a foot pedal.

High-Definition 4K 3D Exoscope (ORBEYETM) in Peripheral Nerve Sheath Tumor Surgery: A Preliminary, Explorative, Pilot Study

BACKGROUND

Surgery for peripheral nerve sheath tumors aims to preserve functional fascicles achieving gross-total resection. Increasing the visualization of anatomic details helps to identify the different layers and the tumor-nerve interface. The traditional microscope can present some limitations in this type of surgery, such as its physical obstruction.

OBJECTIVE

To present a proof-of-concept study about exoscope-guided surgery for schwannomas of the lower limbs, to analyze the advantages and disadvantages of the 4K, high-quality, 3-dimensional (3D) imaging.

METHODS

We analyzed 2 consecutive surgical cases of suspected schwannomas of the lower limbs using the ORBEYE™ exoscope (Olympus). A standard operative microscope was also available in the operating room. All procedures were performed with neurophysiological monitoring, to identify functioning nerves and to localize the tumor capsule safest entry point. The cases are reported according to the PROCESS guidelines.

RESULTS

In both cases, we achieved a gross total resection of the schwannomas; the exoscope provided an excellent view of the anatomic details at tumor-nerve interface, as visible in intraoperative images and in the 3D-4K video supporting these findings. The surgeon's position was comfortable in both cases, although if the co-surgeon positioned himself in front of the first surgeon, the comfort was slightly reduced. The 4K monitor allowed a realistic, nontiring 3D vision for all the team.

CONCLUSION

The ORBEYETM, after an adequate learning curve, can represent a feasible and comfortable instrument for nerve tumor surgery, which is usually performed in a single horizontal plane. Further and wider clinical series are necessary to confirm this first impression.

Novel methods to enhance surgical sperm retrieval: a systematic review

Objectives: To explore the use of novel technologies in sperm retrieval in men with azoospermia due to a production defect. Methods: We performed a Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA)-compliant systemic literature review for manuscripts focussed on novel sperm-retrieval methods. We identified 30 studies suitable for qualitative analysis. Results and Conclusions: We identified multiple new promising technologies, each with its own distinct set of benefits and limitations, to enhance chances of sperm retrieval; these include the use of multiphoton microscopy, Raman spectroscopy, and full-field optical coherence tomography during a microdissection-testicular sperm extraction procedure. ORBEYE and ultrasonography technologies can also serve to better visualise areas of sperm production. Finally, artificial intelligence technology can play a role in the identification of sperm and, perhaps, better-quality sperm for use with assisted reproduction. Abbreviations: AI: artificial intelligence; ANN: artificial neural network; ART: assisted reproductive technology; 3D: three-dimensional; DNN: deep neural networks; FFOCT: full-field optical coherence tomography; H&E: haematoxylin and eosin; ICSI: intracytoplasmic sperm injection; IVF: in vitro fertilisation; MESA: micro-epididymal sperm aspiration; MeSH: Medical Subject Heading; MPM: multiphoton microscopy; (N)OA: (non-)obstructive azoospermia; SCO: Sertoli cell-only syndrome; SRR: sperm retrieval rates; TESA: testicular sperm aspiration; (micro-)TESE: (microdissection-) testicular sperm extraction; (CE)US: (contrast-enhanced) ultrasonography.

Retrosigmoid Approach in the Supine Position Using ORBEYE: A Consecutive Series of 14 Cases

One of the merits of recently introduced exoscopes, including ORBEYE, is that they are superior to a conventional microscope in terms of ergonomic features. Taking advantage of it, the retrosigmoid approach can be performed in the supine position using ORBEYE. We report a consecutive series of 14 operations through the retrosigmoid approach in the supine position using ORBEYE. Fourteen consecutive patients who underwent surgery through the retrosigmoid approach for cerebellopontine (CP) angle lesions in the supine position using ORBEYE were targeted, and surgical outcomes and complications were examined. We evaluated the posture of the operator and the surgical field during this approach compared with those using a conventional microscope. In all 14 cases, all operative procedures were accomplished only using the ORBEYE. There were no operative complications due to this approach. Using ORBEYE, even when the angle of the operative visual axis was horizontal, the operators could manipulate in a comfortable posture. They were not forced to be in an uncomfortable posture that extended their arms, as is often the case with a conventional microscope. Therefore, they could use shorter surgical instruments. As the cerebellum shifted downward with gravity even using slight retraction during this approach, the working space of the surgical field was easily secured. Through this approach, the operators can perform stable microsurgery of CP angle lesions in a comfortable posture. This approach can reduce the burden on the operator and the patient, leading to a refined surgical procedure.

Use of the ORBEYETM Exoscope in General Surgery: The Advent of Video-Assisted Open Surgery

Background. Microsurgery has quickly become the "gold standard" approach for vascular surgical steps during neurosurgery. However, despite its advantages, the microscope has not been widely adopted in general surgery. A new 3D-surgical exoscope, the ORBEYE^TM, has been developed and introduced to some surgical specialties. Herein, we present our preliminary experience with the ORBEYE^TM exoscope as applied to a number of general surgical procedures. Method. Throughout February 2020, 7 patients had undergone varying surgical procedures at our institute utilizing the ORBEYE^TM in some of specific procedural steps where the surgeons felt that the surgery would benefit from more enhanced magnification. Upon completion, all the surgeons who had taken part in the procedure were asked if they had experienced any nausea, dizziness, or eyestrain during its use. Results. The ORBEYE^TM was employed in a number of surgical steps for the following procedures: throughout an inguinal hernia repair, during a duodeno-cephalo-pancreatectomy, for a subtotal gastrectomy, during para-aortic mass dissection, and during Ivor Lewis procedure. None of the surgeons involved in the procedures reported experiencing any nausea, dizziness nor eyestrain, nor any other physical discomforts. Conclusion. To the best of our knowledge, ours is the very first report on the employment of the ORBEYE exoscope during general surgery. Our experience assures us that this highly ergonomic technology with its high-resolution 4K 3D optical system allows the surgeon to perform safe and precise surgery in several dedicated steps in which adequate magnification is required with no adverse effects to the surgeon or the surgical procedure itself.

Minimally Invasive Navigated Foraminal Discectomy via Contralateral Approach Using a 3-Dimensional 4K High-Definition Exoscope: 2-Dimensional Operative Video

This surgical video is the first to demonstrate a novel minimally invasive technique of utilization of surgically navigated foraminal discectomy using a 3-dimensional 4k high-definition exoscope (Sony Olympus). Typical approaches for foraminal disc herniations may involve violation of the facet resulting in subsequent destabilization requiring fusion.1 Although minimally invasive facet-sparing contralateral techniques have previously been described,2 there is continued limitations stemming from rudimentary localization with standard fluoroscopy and impaired visualization with the bulky traditional operative microscope.3 We demonstrate that high-quality real-time navigation is possible using standard Iso-C intraoperative fluoroscopy for 3-dimensional reconstructions, allowing for intraoperative routing. Navigation is particularly advantageous for adjustments in the trajectory of the tubular retractor and for confirmation of complete foraminal decompression. Visualization from the 4k high-definition exoscope also allows for an unparalleled view of the narrow operative corridor and allows for participation from the operative team. Informed consent was obtained from the patient for the surgery in its entirety.

Microsurgery "Under the Eaves" Using ORBEYE: A Case of Dural Arteriovenous Fistula of the Anterior Cranial Fossa

BACKGROUND

One of the merits of exoscopes, including ORBEYE, is that they are superior to a microscope in terms of ergonomic features. We report a case of dural arteriovenous fistula (dAVF) that was cured by direct surgery using the ergonomic advantages of ORBEYE.

CASE DESCRIPTION

A 78-year-old man was found to have dAVF of the anterior cranial fossa incidentally. We performed direct surgery via bifrontal craniotomy. Because the frontal sinus was large, we reserved the frontal bone-like eaves in order not to open the frontal sinus. The vertex of his head was sufficiently down to shift the frontal lobe downward with gravity. During surgery, we set the angle of the operative visual axis of ORBEYE approximately horizontal to avoid the reserved frontal bone. We performed a stable operation using ORBEYE in a comfortable posture.

CONCLUSIONS

ORBEYE facilitates ergonomic microsurgery, even under the eaves, with the angle of the operative visual axis approximately horizontal using gravity.

Initial Experience of ORBEYE™ Surgical Microscope for Carotid Endarterectomy

Background:

Carotid endarterectomy (CEA) is widely performed under operative microscopes. They provide magnified and stereoscopic vision of operative field suitable for precise maneuver. However, the microscope has some shortcomings, which are a narrow field-of-view, shallow depth-of-field, and the operator's fatigue due to fixed gaze posture through eyepieces. To overcome them, we introduced ORBEYE™ Surgical Microscope, which was 4K ultra high-definition three-dimensional (3D) system. We present our initial experience of the system for CEA and discuss its usefulness compared with the operating microscopes.

Methods:

A 66-year-old male presented to our department for the treatment of the left internal carotid artery severe stenosis. He underwent CEA using the ORBEYE™ Surgical Microscope.

Results:

The surgery was successfully completed only under the system without complication. The microscope was set over the operative field. Its wide field-of-view, deep depth of field, and smooth digital zooming allowed minimal repositioning of the microscope. The system provided high quality stereoscopic image of the surgical site, which enables us to perform precise surgery. The 55-inch 4K 3D monitor remarkably contributed to a reduction of the surgeons’ fatigue.

Conclusions:

The ORBEYE™ Surgical Microscope, incorporating 4K 3D video technology, has overcome shortcomings of the operative microscope. This system is highly feasible for CEA and has the certain possibility for other neurovascular surgeries.